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i <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,0i No. 040039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 0 9 5 9 9 6 1 (800)424-9300 015481706 J <br /> 5.Ge g�.rr�atroi are and Mailing Address Generators Site Address(if different than mailing address) <br /> t l ees r er Street,Manteca,CA 95337 Ci of Manteca <br /> 1077 Milo Candini Drive,Manteca,CA 95337 <br /> (209)456-8415 Attn:Greg Showerman <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> s <br /> 7,Transporter pony a e U.S.EPA ID Number <br /> B.Desinated F4 ility Name and Site Address U.S.EPA ID Number <br /> BuEnw low Landfill <br /> 2500 West Lokern Road,Buttonvvillow,CA 93206 <br /> (661)762-6200 CAD980675276 <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) <br /> No. Type Quantity Wt.Nol. 13.Waste Codes ,I <br /> 1. <br /> 0 <br /> NON-RCRA Hazardous Waste, Solids,(Lead) 0 0 I DT 18 Y <br /> w I <br /> z 2. <br /> CD <br /> 3. <br /> i <br /> 4, <br /> t ¢ <br /> I <br /> 14.Spedai Handling Instructions and Additional Information <br /> Soil: 95-100% CIean Harbors Profile Number: C H 13 1 2 3 0 7 B <br /> 'I <br /> Vegetation:0-5% Wear appropriate Personal Protective Equipment as necessary <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION; I hereby declare that the contents of this consignment are fuily and accurately described above by the proper shipping name,and are classed,packa d, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Prima <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent, <br /> I certify that the waste minimization statement idertfied in 40 CFR 262.27{a)(if i am a large quantity generator)or(b)(if I am a small quanti enerator)is true. <br /> GeneratoeslOfferors Printed!€yped Name Signature Month Day Y'ar <br /> (on behalf of the City of Manteca) <br /> 16.Intemational Shipments <br /> Z ❑Impart to U.S. ❑Exportfrom U.S. Port entrylexit: <br /> Transporter signature(for exports only): Date I aving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printe yped Name Signature Month Da Y r <br /> Z Transporter 2 Prin edflyped Name Si nat <br /> � 9 Month Day Ye r <br /> F. I <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ElQuantityty ❑T ❑Residue ❑Partial Rejection ❑Full Reje on <br /> y Manifest Reference Number: <br /> F— 18b.Ahernate Facility(or Generator} U.S.EPA ID Number <br /> J <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Y ar <br /> a <br /> z <br /> 19.HazaMo Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recyding systems) <br /> C 3' 4. <br /> 20.Designated Facilityne Operator.Certification of receipt of ha dons materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Nam, y, ✓ Signature t <br /> r <br /> EPA Form 87 22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE: (IF REQUJ R D) <br /> -- 1 i <br />